Fa Form N 40 - Report Of Birth - Child Born Abroad Of Filipino Parent/s - Republic Of The Philippines Department Of Foreign Affairs
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1
2
3REPUBLIC OF THE PHILIPPINES
DEPARTMENT OF FOREIGN AFFAIRS
FA FORM NO. 40
(REVISED MARCH 2013)
REPORT OF BIRTH
DATE OF REPORT
CHILD BORN ABROAD OF FILIPINO PARENT/S
PHILIPPINE CONSULATE GENERAL, CHICAGO
ID #
DO NOT LEAVE ANY SPACES BLANK. INDICATE N/A IF NOT APPLICABLE.
DETAILS OF CHILD'S BIRTH
1. CHILD'S LAST NAME
5. DATE OF BIRTH (day-month-year)
2. CHILD'S FIRST NAME
6. TIME OF BIRTH
(
) AM (
) PM
3. CHILD'S MIDDLE NAME
7. SEX
(
) MALE
(
) FEMALE
(MOTHER'S MAIDEN NAME)
8. CIVIL STATUS OF PARENTS:
(
) MARRIED
(
) NOT MARRIED
4. PLACE OF BIRTH
(AT THE TIME OF BIRTH OF THE CHILD)
DETAILS OF BIRTH PARENTS (at the time of child's birth)
INFORMATION ON BIRTH FATHER
INFORMATION ON BIRTH MOTHER
9. LAST NAME
10. FIRST NAME
11. MIDDLE NAME
`
12. MAIDEN SURNAME
13. CITIZENSHIP
(AT THE TIME OF BIRTH OF THE CHILD)
14. DATE OF BIRTH (day-month-year)
15. PLACE OF BIRTH
16. OCCUPATION
17. RELIGION
18. HOME ADDRESS
AND TELEPHONE NUMBER
19. NATURALIZED (if foreign born)
20. DATE AND PLACE OF REGISTRATION
AS PHILIPPINE CITIZEN (day-month)
21. DATE OF MARRIAGE (day-month-year)
24. PLACE OF MARRIAGE
22. NUMBER OF PREVIOUS CHILDREN
25. NUMBER OF CHILDREN NOW LIVING
23. SIGNATURE OF PARENT, PHYSICIAN OR NURSE OVER PRINTED NAME
WHEN REPORTED BY MAIL, USE THIS PORTION IN THE PRESENCE OF TWO WITNESSES
WHEN REPORTED IN PERSON, USE THIS PORTION
Declared in our presence this _____ day of ___________________ at _______________________
Subscribed and sworn to before me this _________ day of
First Witness: __________________________________________________________________
_________________ at the Philippine Consulate General, Chicago.
Address : _____________________________________________________________________
Second Witness : _______________________________________________________________
Address : _____________________________________________________________________
SEAL
REPUBLIC OF THE PHILIPPINES
EMBASSY/CONSULATE OF THE REPUBLIC OF THE PHILIPPINES
The foregoing information was furnished by (father, mother, physician, nurse) and supported by (affidavit, physician's certificate, certificate from local authorities). This report has been executed in quadruplicate,
copy issued to parents, copy transmitted to the Department of Foreign Affairs (DFA) in Manila, copy transmitted to the Civil Registrar General through the DFA and copy placed in the files of this Office.
DATE :
SERVICE NO. :
O.R. NO. :
$25.00
FEE PAID :
SEAL
REPUBLIC OF THE PHILIPPINES
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